Endoscopic Diagnosis of Candy Cane Syndrome in Patients With RYGB Anatomy, the Wire Method

Introduction: Candy cane syndrome is a unique complication of Roux-en-Y (RY) gastric bypass that occurs due to a dilated and elongated blind limb that cause gastric pouch contents preferentially to empty towards the blind limb. Patients often present with postprandial epigastric pain, nausea, vomiting, reflux or food regurgitation. Diagnosis may be challenging, as there is limited training for the gastroenterologist about this condition and its endoscopic diagnosis. This presentation aims to provide an illustration about the endoscopic findings of candy cane syndrome and to compare them with the normal anatomy and propose a method to aid with the diagnosis. Case Description/Methods: Case 1-4 show normal RY anatomy, where the roux limb is directly accessible from the pouch with minimal scope manipulation. This orientation makes the pouch outflow preferentially towards the roux limb. In some cases, the roux limb inlet is occupying most of the gastrojejunostomy. Case 5-8 show a typical candy cane anatomy. In candy cane anatomy, most of the gastric pouch outlet is oriented towards the blind limb, only after filling of that space, does an overflow towards an off-axis roux limb would occur. The roux limbs in these cases are eccentric, off-axis and usually demonstrate significant angulation and twisting. Placing a wire and withdrawing the scope helps delineate this off-axis orientation of the roux limb. Fluoroscopic images may illustrate a candy cane physiology where the blind limb and the pouch become full of contrast and regurgitation into the esophagus (as it represents the path of least resistance) may be seen prior to successful emptying towards the roux limb. Discussion: In conclusion, candy cane syndrome is a rare and late complication of Roux-en-Y gastric bypass. Endoscopist's awareness of this issue is crucial to prevent delay in the diagnosis and corrective surgical intervention. These cases highlight how the placement of a wire can aid in the endoscopic evaluation for candy cane syndrome by showing the off-axis orientation of the roux limb and its implications for gastric pouch emptying.Figure 1.: In the candy cane anatomy, the gastric pouch preferentially empties into an elongated blind limb, instead of the roux limb. This rare and late complication of Roux-en-Y gastric bypass is responsible for symptoms such as postprandial epigastric pain, nausea/vomiting, acid reflux and/or food regurgitation. Watch video at https://bit.ly/3kQrY28.